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APPLICATION FOR WELLIPUMP PERMIT <br /> AN JOAQUIN COUNTY PUBLIC HEALTH SERVIW <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.388 <br /> (209( 4683420 <br /> _ C4II �_ � �NONWREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (N 'tr"�^'o�L'T <br /> 6D; <br /> (CDmpku in Triplicate) <br /> APPLICATIO HE V MADE TO THE SAN JOAQUIN COUNTY FORA MIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAOUI OUNTV DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH�SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESS/ORA �1,� I 1 (. / 11,,,, L SF(JC/N'F-vZV PARCEL SSI�IIJZ'IEE�/APNN b� <br /> OWNER'S NAME <br /> //"iitlldr-* M, 10-5 T IVJI('�gDDRES /n�/�2 ,'/ a _'pHONE♦ Z7 <br /> `� /&.P0—y�/ ADDRESSA*3 OJ' � E� -A4j // PHONE K -a-0 <br /> .fw CONTRACTORADDRES�•-- Q bcvo( LICNtO PHONE 77 <br /> TYPE OF WEUL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ONITORING WELL a ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL N J <br /> TYPE OF PUMP) <br /> 13N.❑Repelr M.P. DEPTH PUMP SET FT. FIRST WATER LEVEL D❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL X .Hk-/k-/halrepnB B <br /> ❑DESTRUCTION: �[ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION b 1, DIA.OF CONDUCTOR CASING A114 D <br /> ❑ DOMESTIC/PRIVATE 13 GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC �J/��IY DIA.OF WELL CASING Al D <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME (�Fe'lG� rE <br /> +CEJ/MONITORING GROUT SEAL PRIMPED:%Ys ❑No CONCRETE PEDESTAL By DRILLER:❑Vr 13N. S <br /> APPROX.DEPTH S LOCKING CHESTER BOX/STOVE PIPE 0/4 <br /> S <br /> PROPOSED CONSTRUCTION/=LUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR UCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SMALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIPUBAT/ MUST CALL 3 HOURS IN ADVANCE FOR ALL REQUIRED IN��aS A�1 MB P. COMPLETE T LOWER OAM A PROVISI, —TItI DE <br /> T <br /> PAT PLAN ID,.to SCNeI Scala 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 6. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> T <br /> DEPARTMENT USE ONLY (J <br /> Application Accepted By. �A l//^�.2 V �J1/ Det. I (� —Ls Ary ' <br /> G,.ut Inspection By Date Pump Inspection By Date <br /> Deetructlon Inspection By Det. <br /> Comment: <br /> ACCOUNTING ONLY: AID# FAC/ SI O <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKN/CASH RECEIVED BY DATE PERMIT/SERMCE REQUEST NUMBER INVOICE <br />